Diabetes Management at Camps for Children With Diabetes

S ince Leonard F.C. Wendt, MD, opened the doors of the first diabetes camp in Michigan in 1925, the concept of specialized residential and day camps for children with diabetes has become widespread throughout the U.S. and many other parts of the world. In 2011, approximately 30,000 children attended diabetes camps in North America and over 16,000 more campers participated in one of the 180 diabetes camps throughout the rest of the world. The mission of camps specialized for children and youth with diabetes is to facilitate a traditional camping experience in a medically safe environment. An equally important goal is to enable children with diabetes to meet and share their experiences with one another while they learn to be more responsible for their condition. For this to occur, a skilled medical and camping staff must be available to ensure optimal safety and an integrated camping/educational experience. The recommendations for diabetes management of children at a diabetes camp are not significantly different from what has been outlined by the American Diabetes Association (the Association) as the standards of care for people with type 1 diabetes (1) or for children with diabetes in the school or day care setting (2). In general, the diabetes camping experience is short term and is most often associated with increased physical activity and more controlled access to food relative to that experienced at home. Thus, while away at camp, glycemic control goals are more related to avoiding blood glucose extremes than optimizing overall glycemic control (3,4).Themanagementprotocol aims tobalance insulin dosage with activity level and food intake so that blood glucose levels stay within a safe target range, especially with respect to the prevention and management of hypoglycemia (5). Each camper should have a standardized comprehensive health history form completed by his/her family and a health evaluation form (6) completed by the diabetes care provider that details the camper’s past medical history, immunization record, and diabetes regimen. The home insulin regimen should be recorded for each camper, including type(s) of insulin used, number and timing of insulin injections (if on shots), and insulin pump basal, bolus, and correction dose settings (if on an insulin pump). Records for insulin dosages and blood glucose values for the week immediately before camp should be provided as a baseline. Additional medical information, such as prior diabetes-related illnesses and hospitalizations, history of severe hypoglycemia, previous hemoglobin A1C levels, other medications, significant medical conditions, and psychological issues also should be available to camp personnel and reviewed with diligence by those responsible for the health and well-being of the individual camper. During camp, a record of the camper’s diabetes care progress should be documented daily. All blood glucose values and insulin dosages should be recorded in a format that allows for review and analysis to determine whether alterations in the diabetes regimen are required during the camp stay. A record of the degree of activity and food intakemay also be helpful in determining subsequent alterations in the diabetes regimen. It is imperative that the medical staff have advanced knowledge about the exercise schedule and the meal plan at camp so that they can make appropriate insulin dosage adjustments. Inadvertent schedule delays or schedule changes (such as for rainy weather) can have a significant impact on the risk of hypoglycemia as insulin dosing at the previous meal takes into account the planned activities. If a low-, moderate-, or high-level activity event is originally planned, a replacement activity with an equivalent activity level should be substituted when possible. To ensure safety and optimal diabetes management, blood glucose testing materials and treatment supplies for hypoglycemia should be readily available to campers at all times. Multiple blood glucose determinations should be made and recorded throughout each 24-h period: before meals; at bedtime; before, after, or during prolonged and strenuous activity; in the middle of the night, when indicated for prior hypoglycemia; after an insulin pump site change; and after extra doses of insulin. Use of a continuous glucose monitoring system (CGMS) does not preclude the need to test finger-stick blood glucose. Because exercise may still impact blood glucose 12–18 h after completion, campers who have repeated lows during exercise may also need nocturnal testing. Campers with a bedtime blood glucose level,100 mg/dL and campers on an insulin pump with a blood glucose .240 mg/dL should have their blood glucose rechecked overnight. The intervention for campers with an overnight blood glucose level ,100 mg/dL should be determined based on their insulin regimen and risk for nocturnal hypoglycemia. Campers on insulin pumpswith a blood glucose .240 mg/dL should follow an established pump protocol for ketone testing and changing of the insulin pump site. Campers should be encouraged to check blood glucose levels at times other than the routine times if they have symptoms of hypo-/hyperglycemia or if they have other physical complaints. These recommendations imply that there is adequate staffing and that they have received training in blood glucose monitoring procedures as well as the indications and treatment protocols for hypo-/hyperglycemic events. Every attempt should be made to follow the home insulin regimen of each camper as closely as possible. If a camper’s c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c